Hospital ERs begin taking reservations

Terrence Antonio James, Chicago Tribune

Terrence Antonio James, Chicago Tribune

Deborah L. Shelton and Peter Frost, Chicago Tribune reporters

The first time Erol Uner went to the emergency room recently, he knew something was seriously wrong because fluid retention had caused his legs to double in size. He was seen right away and wound up being hospitalized for two weeks for treatment of congestive heart failure and kidney disease.

People who arrive in the ER with less pressing issues often have to wait for care, sometimes for hours. But when a minor complication sent Uner back to the emergency room at St. Alexius Medical Center in Hoffman Estates, he was able to make an appointment online and practically waltz right in.

"Instead of sitting there in the waiting room with everybody else coughing and with colds, I could wait at home," said Uner, of Schaumburg. "I got there and probably waited less than five minutes."

St. Alexius is one of more than a dozen Chicago-area hospitals that have begun posting ER wait times on the Internet or allowing patients to reserve a place in line from their homes. Administrators say they hope to put an end to the long, unpredictable and uncomfortable waits people associate with emergency rooms.

But adding such conveniences is about more than the warm and fuzzy side of medicine. Hospitals paid by Medicare are now required to report whether they are trying to reduce their ER wait times. And a decline in payments from the government and insurance companies is pressuring hospitals to explore new strategies that will attract new patients and boost revenues.

Some experts also question whether such services might send a mixed message to people with life-threatening symptoms. Those patients shouldn't waste time looking for the shortest line, doctors say; they should go directly to the nearest ER, where they will be seen immediately — regardless of anyone's appointment.

Patients have been slow to take advantage of the services, but the numbers have been growing. At Swedish Covenant Hospital in Chicago, more than 150 patients have made reservations via an online check-in since September, when administrators first offered the service.

"We're trying to use technologies appropriately, and we're trying to be very patient-centered," said Mark Newton, president and CEO at Swedish Covenant. "We're trying to give the patients tools so they can access care more efficiently."

Around 5:30 p.m. on a recent Friday, patients could log on to their computers and decide whether to drive to Rush-Copley Medical Center in Aurora, where the posted wait time was 10 minutes; visit the hospital's other emergency facility in Yorkville, where there was no wait at all, or go somewhere else entirely.

At Edward Hospital's emergency room in Naperville, patients could expect a four-minute wait — or only one minute at its Plainfield location, according to that hospital's website.

Wait time is measured as the average time from arrival and check-in to the time when the patient is placed in a room and treatment can be started.

Edward Hospital's wait times are accessible via app, text, online and phone. In addition, the health system posts the information on digital billboards in Plainfield and Bolingbrook, a move that a hospital administrator acknowledged was as much about brand exposure as customer service.

Experts say hospitals' motive for offering such information is clear: bringing in patients and creating new revenue streams. Emergency departments are a crucial pipeline for people who require hospital stays and tend to bring in the most money.

But hospitals are after even those patients who don't need intense treatment. Once hospitals get new patients in the door, they can funnel them through primary-care physician groups — either owned by the health system or affiliated with it — for follow-up care, raising their chances to hold on to those customers over the long term.

Such strategies reflect the intense pressure hospitals are under as a result of reimbursement cuts from Medicare and Illinois' Medicaid program that start this year. At the same time, as many as 30 million Americans are expected to gain health insurance coverage starting in 2014, creating a vast new pool of potential customers.

For the trade-off to work for hospitals, they must gain a share of those new patients, many of whom will be covered by private insurance, which tends to pay better than government-sponsored health insurance.

At the same time, hospitals are facing a continued decrease in inpatient visits as more services shift to outpatient. In 2011, the last year for which data were available, the number of inpatient days at Chicago-area hospitals dropped by 1.9 percent, the fourth consecutive year of decline, according to the Illinois Health Market Review 2012, an annual report produced by health care consultant Allan Baumgarten.

Those declines run parallel with a building boom in Chicago in which health systems have spent several billion dollars constructing hospitals and expanding existing facilities. That combination of factors leaves many hospitals in a precarious financial position.

"For a hospital to survive in today's environment, they have to have (patient) volume," said Mike Cohen, a principal at Deloitte Consulting's health care consulting practice in Chicago. "Chicago is a fiercely competitive market where everybody is competing for volume and business, and this is another vehicle to do it."

Other observers say this particular strategy has drawbacks, raising concerns about safety and added costs.

Dr. David Seaberg, immediate past president of the American College of Emergency Physicians, said patients having heart attacks or other life-threatening problems might waste valuable time searching for the shortest wait time instead of going to the nearest emergency room.

"It's never bad to give patients information, but most of these services are pure marketing ploys," Seaberg said.

Efforts to lure more people into emergency rooms also may drive up charges for patients and their insurers, including taxpayer-funded government programs like Medicaid. Patients with less serious issues like sore throats, colds and the flu should be seen in less expensive venues like doctors' offices and urgent-care centers, some experts say.

"If what you're trying to do is get primary-care patients in the ER, that's bad for the system," said Scott Rabin, who leads Buck Consulting's national hospital and health care practice.

Health systems that advertise emergency room wait times and appointments tend to be the ones with smaller primary-care networks, and therefore fewer physicians to feed patients into hospitals, experts said. Many hospitals have snapped up physician groups as a way to drive volume, but others have been hesitant, because they either lack deep pockets or aren't sold on the concept.

Edward Hospital in Naperville, which had about $586 million in net patient revenue in its fiscal 2012, employs about 100 physicians, including about 40 primary-care doctors in Edward Medical Group. About 90,000 patients used the hospital's emergency departments in Naperville and Plainfield last year, a figure that's grown significantly since it began advertising wait times, said Brian Davis, vice president of marketing and government relations.

By contrast, the much larger Rush University Medical Center sees only about two-thirds that number in its new emergency department, and that's after its new West Side facility fueled a 17.5 percent bump in 2012.

Dr. Dino Rumoro, chairman of the emergency department at Rush, said he has no plans to post wait times, largely because he fears such policies could dissuade patients who need immediate care from going to a hospital.

"I'm waiting to hear of that one patient who thinks he's having indigestion, considers coming in but sees the wait times are too long, takes some Mylanta, and someone finds him the next day at home dead," he said.

"I don't like that idea," Rumoro said of publicizing wait times. "I think it's dangerous, and I don't think it sends the right message."

He is, however, warming to the idea of allowing people to make appointments in the emergency department because it could help the hospital better manage patient volumes by allowing those who don't require critical care to select time slots when demand is low. But Rumoro said any such system would need to include a proven mechanism to divert patients with potentially fatal conditions.

Administrators who use online reservations said they made sure such a mechanism was built into their system. Adrienne Seloover, director of emergency and trauma services at St. Alexius, said the hospital's website directs patients with life-threatening symptoms to the nearest emergency room. A person who uses key words such as "chest pain" on the online appointment form triggers an alert that advises calling 911 or going to the closest ER, she said.

"All of our charge nurses have been trained in the system and review every registration that comes through our system," Seloover said. "If there is anything questionable about the patient's symptoms, we call the patient at home to get additional information."

Hospital administrators say they are trying to meet the needs of patients seeking care.

Dr. Tom Scaletta, medical director of emergency services at Edward's Naperville emergency department, said some patients have told staff that they left other emergency rooms to go to Edward because they checked and saw that wait times were shorter there. About a quarter of the hospital's admissions come through the ER.

"I know what we're doing is effective," said Edward's Davis. "We have hundreds of people every month who tell us they choose us because of our policy to post wait times. It's transparent, it's honest and it keeps our ER people on top of their games."